Care Navigator (FT) | Population Health | Ames | 2025-029

GENERAL SUMMARY OF DUTIES: Collaborates with all members of the multidisciplinary healthcare team to ensure the delivery of high quality and cost effective care, as evidenced by coordinated transitions of care, achievement of select quality outcome metrics, and appropriate utilization of health management programs and resources.

SUPERVISION RECEIVED: Reports directly to Population Health Director

SUPERVISION EXERCISED: None.

TYPICAL PHYSICAL DEMANDS: Requires prolonged sitting, some bending, stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, etc. Occasionally lifts and carries items weighing up to 50 pounds. Requires normal range of hearing and eyesight to record, prepare, and communicate appropriate reports.

TYPICAL WORKING CONDITIONS: Work is performed in an office environment.

EXAMPLES OF DUTIES: ( This list may not include all the duties assigned.)

• Identify any gaps in care through internal or external reports, and work collaboratively with the provider and healthcare team to close the gaps to maximize the patient’s healthcare status.
• Proactively identifies patients health needs, and works in collaboration with the provider, care manager, and healthcare team to ensure preventive and /or needed care is arranged.
• Assists in patient outreach to achieve optimal patient outcomes.
• Provide follow-up on inpatient admissions and emergency Department visits; working collaboratively with the provider and healthcare team to coordinate post discharge, appointments in the clinic to prevent unnecessary readmissions/visits.
• Primary access to establishing patients with McFarland Providers or through multiple areas of input.
• Assist with record completion: accurately entering reports from outside health care facilities and providers.
• Tracks quality outcome results for defined populations, and shares the results with providers and healthcare team.
• Serves as a community face of Population Health and McFarland Clinic by attending local health fairs and community events to promote the department.
• Provide support to the Population Health department, the patient and the patients care team.
• Utilizes Population Health Intelligence to proactively identify high risk patients to avoid admissions and readmissions to hospital and work closely with the PCN team to enable them to deliver personalized care
• Utilize Population Health Intelligence tools were needed to support other patients in the PCN
• Performs other tasks as assigned.

PERFORMANCE REQUIREMENTS:

Employee-Level Behaviors:

At McFarland Clinic, our employees play an essential role in our ability to achieve our organizational vision. As described in McFarland Clinic Employee-Level, Vision Related Behaviors, staff is responsible for:

• Earning trust as compassionate, professional and respected leaders.
• Coordinating the efficient delivery of patient-centered, quality health care.
• Accomplishing the highest levels of quality and satisfaction for our patients.
• Recognizing the vital connection between the well being of our staff and our patients by ensuring an outstanding work environment and a shared accountability for our patients’ health.

Knowledge, Skills, & Abilities:

• Ability to work independently as well as a team member.
• Ability to read, write, understand and speak fluent English.
• Proficient use of standard office equipment including computers, fax machines, copiers, printers, telephones, etc.
• Skilled in appropriate use of EHR

Days: Monday - Friday

Hours: 8:00 AM - 5:00 PM

Education:

• Associate Degree in Health or Social Sciences preferred.

Experience:

• Three years experience in a multi-specialty clinic or similar organization. Experience with population health, care coordination, and/or disease management programs preferred.

Certificate/License:

• LPN, CMA preferred

Benefits

McFarland Clinic offers a comprehensive benefits package, including health and dental insurance, 401(k), and PTO. Click here for details.

McFarland Clinic is central Iowa's largest physician-owned multi-specialty clinic. Join our team and join a group of caring professionals, dedicated to providing Extraordinary Care, Every Day! We value quality care and extraordinary service, trusting relationships and an exceptional workplace. Our organization has more than 75 years experience of caring for people. We welcome applicants who can help us enhance the health and well-being of our patients and communities we serve.

McFarland Clinic is an Equal Opportunity Employer. McFarland Clinic makes every effort to comply with all requirements of federal, state, and local laws relating to Equal Employment Opportunity.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)